How old is your heart?

An interview with Jess Goodman, MD, iHeart President and Founder and Sarah Goodman, CEO of iHeart, conducted by April Cashin-Garbutt, MA (Cantab)

How can you measure the biological health and age of your heart?

Jess Goodman, MD: There have been a number of ways this has been done conventionally in the past. Blood pressure is one indicator.

Other risk indicators include family history of heart disease, level of cholesterol and exercise testing, where you can get heart rate up to a certain percent of the maximum rate and then see how long it takes for the heart rate to recover - that's referred to as the heart rate recovery time. These are all indications of heart health.

What we've tried to do is to use the latest research that shows cardiovascular illness and heart health can be judged using a single, very powerful parameter: the aortic pulse wave velocity, which relates to aortic stiffness. We would like to give this to people as something they can use in a simple and easy fashion by means of a fingertip sensor.

The volume of research related to the relationship between aortic stiffness and cardiovascular risk is extensive, yet it's not used extensively because of the difficulty involved in conventional measurement of aortic pulse wave velocity for assessing aortic stiffness.

Can you please give an overview of iHeart? What’s the behind this heart monitoring technology?

Jess Goodman, MD: We are hoping to give people access to this aortic stiffness parameter. It's a parameter that relates not only to heart health; there is overwhelming evidence in the scientific literature that aortic stiffness is able to predict the risk of death from all causes.

It seems like a bit of an incredible statement to make - that a single parameter can give you a sense of your risk of dying from any cause - but that is actually the case.

To understand this, it's necessary to reflect back on very old understandings of health that are common to exercise arts such as yoga and tai chi that encourage people to keep the entire body mobile, especially along the spinal axis and the core regions of the body that are flanked by the spine in the back, the chest wall, the diaphragm, the pelvic cavity and the brain in the skull.

These areas require motion. There is a massaging action that promotes circulation in the internal organs such as the liver, spleen and kidneys and circulates the fluid within the spinal cord and around the brain's cerebrospinal fluid, which has the effect of maintaining organ function and sustaining life.

We're actually trying to be a bridge between that ancient wisdom that says the entire body, especially along the spinal axis, needs to maintain mobility and modern scientific evidence that aortic stiffness is a wonderful way to assess core mobility and gain benefit from exercise; even simple things such as walking, a good diet and lowered stress levels can make a difference.

Aortic stiffness is, to some extent, a surrogate for stiffness along the spinal axis because the aorta lies immediately in front of the spine.

Our vision is to give people access to a very powerful single health metric that can guide them towards good lifestyle choices and help them to feel better and live longer.

How does the technology work?

Jess Goodman, MD: In the arterial pulse signal of every single person's fingertip, there is a 3-wave pattern nobody has really recognized before we developed iHeart.

That's because when you look at the fingertip arterial pulse signal using a conventional oximeter (the fingertip device that measures blood oxygen levels), you're actually looking at a signal that's been extensively processed and filtered in a particular way that removes some of the low frequency content. That's where the signal that defines aortic stiffness has been hiding.

The iHeart oximeter has the world’s highest sampling rate and highest resolution available commercially. It samples the pulse signal 200 times a second with 20-bit resolution and absolutely no high-pass filtering.

When you obtain the signal in this way, you can see a wave within the pulse signal that is called the aortic reflected wave. When the heart beats, that wave strips down all the blood vessels of the body, all along the arterial tree right to the very end.

The aorta is the body's largest blood vessel and it runs from the heart through the chest and abdomen. This primary pulse wave ripples along the walls of the aorta. As the aorta gives off branches and then divides, reflections of this primary wave head back towards the heart.

Various reflections come together to form one reflected wave that, in a young person, gets back to the heart just as the heart goes from its contraction phase to the relaxation phase, from systole to diastole.

The reflected wave maintains pressure in the aorta, allowing blood flow into the coronary arteries to feed the heart muscle. It's a beautiful and subtle kind of relationship that enables the heart to get fed during its relaxation phase.

This reflected wave travels along the arteries, past the heart, onto the finger and with the iHeart internal age device, we can pick up this reflected wave and develop an index based on its timing, which we use to calculate aortic pulse wave velocity and aortic stiffness.

In the iPad version of the iHeart app, we actually include a signal analysis screen that shows with a red line exactly where that reflected wave occurs, when it begins. We're trying to do this in a very transparent way and show people that in every person's arterial pulse signal, you can see this aortic reflected wave that determines the shape of your pulse signal and is related to aortic stiffness.

We use a Bluetooth low energy (BLE) to communicate data between the iHeart fingertip device, iOS devices, and soon we'll be able to do this with Android devices. That's how it communicates.

In what ways does iHeart differ from traditional equipment used to measure Aortic Pulse Wave Velocity?

Jess Goodman, MD: Aortic pulse wave velocity is usually measured with very expensive and complicated technology. It requires a skilled technician to precisely place a pressure sensor over the carotid artery in the neck and the femoral artery in the groin, measure the distance between these two sensors and then collect data. It's cumbersome.

The equipment costs in the range of about US$25,000 and it's not used in doctors' offices because it is too expensive and too complicated.

We're hoping to show that this can be done in a much simpler and easier fashion. We would love for people to gain access to this metric and, in time, once we have the ability to publish data, we would like physicians to use this to identify people who are at an increased risk of heart disease and, actually, dementia, and give those people additional advice, both in terms of lifestyle counseling and treatment to lower their risk and allow them to live without having to suffer from heart disease or cognitive impairment.

How accurate is iHeart? What studies have been carried out to test this?

Jess Goodman, MD: We actually purchased the Gold Standard System to measure aortic pulse wave velocity. It's called the SphygmoCor, a system manufactured by a company called AtCor.

We compared the iHeart readings with the SphygmoCor readings and found that there was a very good correlation. We then did a head-to-head comparison and we found that we actually are able to produce data which is comparable to the data that you would achieve using the SphygmoCor system.

We have begun work with Ryerson University to produce data that can be published in a peer reviewed journal, to further promote the benefit of using fingertip pulse analysis for calculation of aortic pulse wave velocity. That is independent research that's ongoing at the moment.

We have spent the summer developing the technology to measure aortic pulse wave velocity using the widely used carotid femoral method. It took several months to get that together. Moving forward, again, we are going to do a head-to-head comparison between iHeart and the carotid femoral approach in a way that is quite objective and allows us to publish the results.

Are there any published papers at the moment?

Jess Goodman, MD: There are many published papers on the use of aortic pulse wave velocity to measure aortic stiffness and the relationship of aortic stiffness with many illnesses, but we have not published anything yet with respect to the relationship between iHeart and the conventional carotid femoral measurement.

We do have data from in-house studies with graphs showing the correlation between iHeart and SphygmoCor aortic pulse wave velocity results. We've also collected data on many thousands of individuals using iHeart.

You can clearly see that the relationship between age and the iHeart reflective wave index is exactly comparable to published studies with regards to aortic pulse wave velocity and specifically SphygmoCor data.

iHeart Internal Age - Validation

Have you found that if people make positive health changes, they can see a reduction of their physiological heart age?

Sarah Goodman: Yes. When we started, we did a beta test with individuals in the health and wellness space who had clients such as personal trainers, nutritionists and health coaches.

They really liked iHeart because you can see changes quite quickly with positive lifestyle choices. Especially for a personal trainer, the changes are seen quite quickly when somebody does start a workout regimen or changes their diet.

You'll see the pulse wave velocity score going down. We’ve turned that score into an internal age because it’s a bit more of an emotional hit and people can understand it.

When we are doing demos or talking with potential partners or consumers and we start talking about aortic pulse wave velocity and all the science, people glaze over a little bit. We really wanted to simplify things for people so they could really understand it and have a bit more motivation to change that number.

I've had a personal experience with iHeart. I was in a pretty big accident about a year and a half ago. I was hit by a car, as a pedestrian.

I've been using iHeart for a couple of years, reading around my actual age, which is a pulse wave velocity score for somebody my age. I'm 32. After I was hit by a car and my body had suffered from trauma and I couldn't walk for a few weeks, my pulse wave velocity score shot up and I was reading 85 years old internally.

My body had had a shock and I'm actually still working to get down to my original number, but using iHeart, I've been able to figure out exactly what works for me and what doesn't. I used to be very into fitness. I was a fitness trainer at one point and loved resistance training, going to the gym and things like that.

I learned while testing with iHeart that that wasn't having a positive effect on my body anymore and I started doing a lot of yoga. Then I realized that lengthening my body was what was needed to help it heal back to almost the original state.

We've done tons of tests and when people are quite motivated, they see changes very quickly. We just released a professional version for health and wellness professionals and we've had a bunch of personal trainers. Some physicians are using iHeart already.

People really like it because they can provide immediate validation that an hour-long training session or even counselling where you're getting something off your chest and lower stress levels a little bit, will provide a bit of an improvement.

Then, that gives the user some motivation to keep up with those changes. It is a great motivational tool. I test all the time because I love seeing the results

We have really good analytics on our application and we can see how much people are testing each day. People use it like they would a weight scale or blood pressure monitor, where you test at the same time each day and multiple times a week if you like. We have so many people who are testing all the time.

It's really interesting because when you do start seeing those changes, then you want to keep pushing. Even in a corporate wellness space, we've noticed an element of competition and gamification of the app. It is a great result.

If people want to start competing on who can be the youngest, we're totally into that. We made the products to make people healthier and live longer and if they can make a game of it, that's great.

Jess Goodman, MD: In its measurement of the aortic pulse wave velocity, iHeart senses two things. One is aortic stiffness and the other is blood pressure. Those are the two factors that will affect aortic pulse wave velocity the most.

In the short term, any blood pressure effects will change your readings. As Sarah said, if you lower your stress or you do a workout, you will see a change, but those are short-term blood pressure changes.

To get very consistent readings, we encourage people to monitor using iHeart in a way thatadjusts for blood pressure effects before every reading. We ask people to sit in a relaxed way for at least a couple of minutes and avoid caffeinated drinks, exercise, smoking and meals.

It's very similar to measuring blood pressure. You want to do it in a way that avoids those other influences that can give you readings that might not be as accurate as they could be.

What impact do you hope iHeart will have?

Sarah Goodman: Dr. Goodman created iHeart because we really wanted to provide people with a new and exciting way to monitor positive changes in their health and wellness and be able to do it in the comfort of their own home.

There are so many wearables out there that monitor motion, calories and so on - that's not something that we're interested in doing. We're interested in showing people the changes they can actually make to their internal health.

You may have a Fitbit and be taking your 10,000 steps a day, but what are those steps actually doing for you internally? We want to show people how their lifestyle choices are affecting them on the inside and potentially make tweaks so they can optimize healthy living to get the lowest score possible.

For example, people who are aged around 60 and have a high pulse wave velocity score can reduce that quite significantly and live a lot longer.

Jess Goodman, MD: Just this morning I had a meeting with a couple of gentlemen that are part of a company that manufactures integrated circuits. We're hoping to move ahead with a second generation iHeart with additional properties.

I measured them and one of the guys was strong, really well built and very proud of himself. He ran every day and his heart rate was in the high 40s/low 50s. He was in great shape, but his iHeart reading was much older than his chronological age.

I asked him what kind of training he does and he said he runs and lifts weights. He doesn’t do any stretching at all.

He appears fit on the outside, but inside he's stiff and, with each breath, he is not getting that beautiful drop of his diaphragm, the expansion and relaxation of his chest wall, and a massage of his internal organs that's going to promote good health and long life. As Sarah said, it helps people to look inside and to get feedback in terms of what activities work.

I can't overemphasize the importance of Sarah to this project. I developed a prototype that was very attractive to engineers. It had lots of graphs and numbers and was one of those things that would be absolutely impenetrable to the consumer.

What Sarah has done is use her experience as a fitness trainer and a holistic nutritionist to give people an intuitive understanding - a single metric, a simple look and enjoyable design that will help them think “yeah, I can understand that. It's my internal age. That's simple."

I'm just so grateful that Sarah has taken an idea I had and turned it into a product that people can use to get the feedback that will lead them in the right direction.

Sarah Goodman: We have users all over the world, which feels great and is amazing to us. I think we have users in over 700 cities across the world.

People give us their feedback all the time about how iHeart has helped them figure out what works for them and how they're more motivated. Having that feedback is wonderful and we hope to bring iHeart to more people around the world.

Heart disease is prevalent in many areas of the world and with the latest studies that have come out about increased arterial stiffness being a risk factor for brain-related dysfunction in even 35-year-olds, we can also help people see, by using iHeart, that they may be at risk of something like that in the future.

Jess Goodman, MD: Exactly. Among young people in their 30s, aortic stiffness and aortic pulse wave velocity can predict who is likely to have cognitive decline and develop dementia. It can also identify people at risk of heart disease long before any clinical features develop.

If we can help even just a few people realize they may be at risk and help them change their lifestyle habits and exercise regularly, eat well, lower their stress levels, feel better and live longer, then we've done a good job.

What feedback have you received so far?

Sarah Goodman: We've got thousands of users at the moment. We have some pretty great early adopters who have benefited from the whole process of determining what works with the product and what they do and don't like. I think that, as such a small team, we can change quite quickly and pivot, which is great because we can make changes for our users really quickly.

We have made changes like that. Like I had mentioned before, we have just introduced a professional model because people were asking for something that they could use with their patients and clients so that they could share this information, do a test every time they come in and give the clients a report to take home on aortic pulse wave velocity.

Right now, when a consumer buys iHeart online, they receive the hardware and then with that hardware, a free application that they could use with their friends or family if they wanted them to be able to share it. Each of those user profiles has an online dashboard where they can see all of their results. We want to add in communication as well and potentially gamify it.

Then, with the professional model, it's the same hardware that you would order, but what is different is that there is an app where you get 1,000 user profiles that you can start for your patients or clients.

After each pulse wave velocity test, a detailed report is sent out to that patient or client. Each of those 1,000 users have an online dashboard where they can review all of their information and learn more about what the metrics mean.

We have a lot of resources and we produce content about twice a week. Then, we also want to be able to add in some more communication through the health and wellness professionals and their clients.

What are VitalSines' plans for the future?

Jess Goodman, MD: One of the things that I am passionate about is developing an understanding of what the body looks like when monitored on a continuous basis. Using iHeart and looking at the pulse signal from the optical sensor, I have just been amazed at the changes when somebody just goes from a sitting position to a standing position, for example, and their blood pressure drops, the heart rate rises and then returns to baseline.

Amazingly, there are several very clearly defined patterns because this is controlled by the unconscious or autonomic nervous system. All of a sudden, we've now got a way to look at the function of the brain on almost a real-time basis.

When you look at heart rate, blood pressure, breathing, core mobility, aortic stiffness and so forth using an optical sensor and marry that with a 9-axis motion sensor and a sensor connected to a Smartphone that knows where you are, who you're standing close to and so forth, then you have a picture of human life that has never been seen before.

I think this will change the way people understand themselves. I think it will change the way we as a society manage our health, both individually and collectively. We're planning to build the way for a third party developer to use that data to create bioapps and then allow those to be sold at a bioapp marketplace - very similar to the Apple App Store.

This will allow exploration of this brand new data, this new perspective on human life, in a way that leapfrogs the ability of science to explore it.

Initially, it will have very little meaning and very little value, but we want to show people that, on a moment-to-moment basis, they can now assess what happens just if they go for a walk, get stressed, are in a place where they feel uncomfortable, have a good sleep or maybe do not have enough water to drink over the course of the day.

I want every person to be able to monitor themselves the way we monitor cars and aircraft. Human beings are a valuable engine, so I think we deserve it.

Basically, the key thing that I think Sarah and I want to communicate is that aortic stiffness is a single metric, with great power to guide people towards making good lifestyle decisions that will lead to better health and a longer life.

Prediction of Cardiovascular Events and All-Cause Mortality With Arterial Stiffness Journal of the American College of Cardiology 55(13):1318-27 March 2010 Charalambos Vlachopoulos et al.

About Jess Goodman

MD President and Chief Medical Office, VitalSines

Jess is a Physician in General Practice with experience in worn personal health monitoring electronics development and deployment.

He is passionate about giving individuals better ways to visualize, monitor, and manage their health.

Dr. Goodman spent years working to make this concept accessible and useful for people around the world. After many years, he and the iHeart team developed the iHeart pulse analysis system.

About Sarah Goodman

CEO VitalSines

Sarah has worked on iHeart Development since generation 1 prototype.

Her experience in marketing and public relations as well as her designations as both a registered holistic nutritionist (RHN) and certified personal trainer (CPT) provide her with the knowledge and skills to be an effective leader and communications professional for the VitalSines team.

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